Breast Cosmetic Surgery

Breast Enlargement (Augmentation)

Breast Reduction

Breast Lift

Breast Asymmetries

Fat Transfers

Implant Problems

BREAST ENLARGEMENT (Augmentation)

Breast Enlargement

The procedure

This popular and very successful procedure is obviously for patients wishing to increase the size and fullness of the breast and/or remove some minor drooping. Patients tend to be those that have either always had small breasts or those that have lost breast volume following pregnancy. For a small group of patients with very different sized breasts then you may wish to have surgery on one side only.

The procedure involves the placement of an implant under the breast tissue. This can be placed directly below the breast (sub-glandular placement) or under the muscle (sub-muscular placement). Access to place the implant can be through the armpit (trans-axillary approach), nipple (trans-areolar approach), or most commonly under the breast at the crease (infra-mammary approach).

Under the Breast

Implants placed directly under the breast fills any laxity slightly better. It can, therefore, give a slightly better ‘lift’. It is less discomfort to have done.

Under the Muscle

Placing the implant under the muscle gives more ‘padding’ over the implant and therefore can reduce the chances of feeling or seeing the implant edge. This is often preferable in very thin patients where the ribs are easily noticeable and the implant coverage would be poor. Under the muscle also has a slightly lower capsule formation. It does require the partial division of the muscle, which is uncomfortable and increases the risk of bleeding slightly.

THE POSSIBLE APPROCHES

Axilla

The armpit incision avoids a scar on the breast. However, it does

leave a scar in the armpit, which can be visible in some patients,

and it is only good for sub-muscular placement.

Breast Crease

Under the breast crease (infra-mammary approach) is most frequently performed and can be used for all operations. The scar heals well and can be hidden in the crease.

Nipple/Areola

The nipple approach is useful if the nipple is larger and the breast is small. Some concerns remain regarding potential higher infection risks for this type of approach, but if you wish to have this option the risk of infection can be discussed during your consultation.

Fat Injection Techniques

This method involves using the patient's own fat to increase fullness or volume in the breast or face, for both cosmetic and reconstructive purposes.

The fat is removed by Liposuction from the thigh or abdomen, specially prepared and re-injected into the area using small cannulas. This procedure is used for both breast augmentation and breast asymmetry (differing breast sizes). It is also a well-established technique in treating defects or indentations following breast cancer removal.

The great advantage of the technique is the ability to permanently enhance these areas with the patient's own fat. The disadvantage is the unpredictable survival of the fat. Usually, about 50-60% of the injected fat survives and the treatment may need repeating. There are virtually no scars and depending upon the area to be treated it is performed as a day-case under local or general anesthesia.

Fat grafting is often an associated/simultaneous procedure for enhancing the contour results in Breast Augmentation as well in Breast Lift with or without an implant placement.

Scars

The quality of scars varies between patients. The scars will depend also on the technique used (as above). They tend to be quite pink in the first 6 weeks moving to purple over the next 3 months and then fade to white. Most patients will form very good quality scars over time. Some reach this quickly, others take longer or may form raised or stretched scars. How other wounds have healed in the past may be an indication.

Smoking

If you are a smoker, try and stop for a minimum of six weeks before and five days after surgery as it can reduce the chances of complications.

Breast Screening, Self-Examination & Breast Cancer

Before any Cosmetic Breast procedure is mandatory, depending on the patient's age, to perform an Ultrasound exam and/or a Mammography. Anyhow there is no direct link between silicone implants and an increased risk of breast cancer. In fact, the incidence of breast cancer in patients with implants is marginally lower. If you are considering having implants and have a family history of breast cancer, we would recommend mentioning this in your consultation and having a specific breast screening before proceeding.

Implants however will not interfere with future screening mammographies and/or ultrasounds exams.

Length Of Surgery

The operation takes 1.30-2.00 hours depending on the type of technique used to insert the implants.

Nights In Hospital

Usually one night but in selected cases, a Day Surgery stay can be considered.

Dressings

Dressings will be reduced either on the day of discharge or a few days later. The wounds will then be checked again at 7-10 days.

Washing

The glue dressings are water-resistant so you can shower after a few days after surgery. However, we suggest avoiding vigorous washing over the wounds. After this time you can be less cautious.

Drains

Drains may be required. They are usually used for implants and are kept in for 24-48 hours.

Bras

You should bring a soft (non underwired) sports bra in the planned new cup size into the hospital with you. The bra should feel comfortable, whilst still providing support. You will need to have two bras at home that can be worn on rotation. You will be able to wear an underwired bra after 8 weeks; this should be properly fitted to your new shape and size.

Time To Exercise

Patients usually feel able to walk a distance at 5-7 days, swim by 14 days (if fully healed). Strenuous exercise (aerobics etc) should be avoided at least for 6 weeks.

Post-Operative Instructions

Day 1-4 You should be taking it very easy. You should not be looking after very young children or doing housework without help.

Normally after 7-10 days, you can start doing more exercise including walking for longer, shopping, etc. You will have very little pain by the end of this period.

Driving

Although you may feel able to drive by 7-10 days, you need to be completely free of discomfort.

Recovery and the final outcome

You should expect some visible bruising and some swelling in the breast. This will last for 2-3 weeks. Your breasts will be for 2-3 months slightly firmer and higher than the expected end result. You will have good shape immediately but it will soften and become more natural over time, continuing to improve over 6 months.

Follow up

Even after the first 2-3 weeks, the follow up is important at 3 months as well at 6 and 12 months after the surgery.

Potential Complications with Breast Augmentation

This is a routine operation that is a great success for the vast majority of patients. However, as with any procedure, it is very important you understand what can go wrong as well as right. The potential complications are listed below.

Loss or altered nipple sensation: It is common to initially have a loss of sensation following surgery, but it returns for the vast majority of patients. It is also common for it to affect only one side of the breast. Less than 5% of patients will experience a permanent loss of sensation.
Remaining asymmetry: Most women have different sized breasts and it is likely that surgery will improve any asymmetry. However, it is possible for one breast or nipple to be marginally different to the other side after surgery.
Scars: The quality of scars varies between patients.
Wound breakdown: Although possible it is very uncommon.
Bleeding: A blood clot can collect in the breast, which would result in going back to the theatre for its removal. However, if a blood clot is to form it will be within the first 24 hours post-surgery. Blood clotting results in approximately 2% of patients.
Breastfeeding: About 80% of women are still able to breastfeed after breast augmentation.
Infection: Very uncommon but if an infection does occur it can be serious and sometimes results in removal of the implants.
ALCL: A very rare localized lymphoma cancer associated with textured implants. Usually presents with swelling of the breast and occurs in approximately 1 in 5,000 to 1 in 100,000 cases depending upon implant type. See the BIA-ALCL section.
Seroma: Small fluids collections around implants can occur and are usually not detectable. Larger seromas may need aspirating with a needle. Most will be benign but very rarely can be a sign on ALCL so testing would be done.
General operation risks: Chest infections, Blood clots in the leg or lung (DVT or PE). Although rare it is important to avoid these by not smoking, being excessively overweight, and moving about after surgery as soon as possible.
For implant-related problems and capsule formation (hardening of the implant) please see the 'Silicone Implants' section.

Breast reduction

BREAST REDUCTION

The Procedure

There are many problems associated with large or heavy breasts including discomfort, neck and shoulder pain, backache, and skin irritations. The patient can refer to difficulty with exercise and finding clothes/underwear to fit.

There are different types of breast reductions. During the consultation will be discussed the most suitable type of procedure for the patient based on their breast size and specific needs. The scars and final type of shape will vary according to the type of procedure used. A reduction in size and shape is achieved through lifting/repositioning the nipple, while still connected to the breast, removing the excess skin and breast, and then reshaping the remaining into a smaller and up-lifted breast.

Scars

The scars will depend on the technique used (as above). They tend to be quite red in the first 6 weeks, becoming purple over the next 3 months, and then fading to white. During this time we would recommend keeping the area out of strong sunlight. Most patients form very good quality scars over time. Some reach this quickly, others take longer or may form raised or stretched scars.

Smoking

If you are a smoker it is much better to try and stop for 3 months prior to surgery to maximally reduce your chance of problems.

Length Of Surgery

The operation takes 2.00 - 4.00 hours depending on the type of technique used and the size of the breast.

Nights In Hospital

Usually one night.

Dressings

You will wake up with dressings on the wounds and elastic support tape on the breasts. The dressings will be replaced on discharge or after 2-3 days and must be kept dry. You will then return the following week for a wound check.

Drains

Drains may not be required during this procedure. When used they will remain in for 24-48 hours.

Bras

Postoperative period

People vary in recovery; younger patients tend to experience more discomfort with this type of surgery, but patients should allow at least 2 weeks of recovery. Patients with highly active physical jobs may require a longer period before going back to work.

Time To Exercise

Patients usually feel able to walk a distance at 5-7 days, swim by 2-3 weeks (if fully healed). Strenuous exercise (aerobics etc) should be avoided for at least 6 weeks.

Post-Operative Instructions

Day 1-4 You should be taking it very easy! You should not be looking after very young children or doing housework.

Day 5-14 You can start doing more gentle exercise including walking for longer, shopping etc. You will have very little pain by the end of this period.

Driving

Patients should avoid driving until they are completely free of pain and restriction and be able to confidently perform an emergency stop. This is to ensure they will be covered by their insurance policy. It may take two or three weeks to recover sufficiently.

Follow Up

We will check your wound at day 5-7. You will then have an appointment with Stephen McCulley at 3 months. You will not be charged for any follow-up appointment relating to your surgery.

Recovery And Final Outcome

You should expect some bruising and swelling in the breast, which will last 2-4 weeks. It is common to experience some leaking from the wounds for the first week as they begin to heal. At this point, your breasts will be firmer and higher than the expected end result. By 4-6 weeks the breast will be much softer and should be a good shape. They will continue to improve constantly over 6-12 months.

Potential Complications With Breast Reduction

Nipple/Areola skin loss: This is extremely uncommon (less than 0.5%) and occurs if the blood supply to the nipple is insufficient. If this happens the nipple will be lost and be replaced by a scar. Although rare, the risk is increased in any patient by smoking, obesity, and old age. There is also an increased risk if the reduction is for very large breasts.
Loss or altered nipple sensation: This occurs in 20% of patients, and can affect normally only one side. The risk is increased for patients with very large breasts.
Remaining asymmetry: Most women have different sized breasts and it is likely that surgery will improve symmetry. However, it is possible for one breast or nipple to be marginally different from the other side after surgery.
Scars: The quality of scars varies between patients.
Wound breakdown: Patients who undergo breast reduction can experience problems with wound healing, especially in the area of the breast crease. This occurs in about 5% of patients and takes a number of weeks to heal.
Bleeding: A blood clot can collect in the breast, which would result in going back to the theatre for its removal. However, if a blood clot is to form it will be within the first 24 hours post-surgery. Blood clotting results in approximately 1% of patients.
Infection: quite uncommon but if occurs you will need a course of antibiotics.
General operation risks: Chest infections, Blood clots in the leg or lung (DVT or PE). Although rare it is important to avoid these by not smoking, not being excessively overweight and moving about after surgery as soon as possible.

Mastopexy

BREAST LIFT

A breast lift (Mastopexy) is for patients who are unhappy with the shape of their breasts, usually because they feel the breasts are too droopy but are generally happy with the size of the breasts. This may have always been the case or more commonly following children and with advancing age. In selected cases, breast re-shaping can be safely coupled with breast enlargement. This obviously creates a larger breast but is also used when more fullness at the top of the breast is a priority. In some patients, this needs to be separated into two operations to get the most predictable outcome.

The Procedure

There are many different types of breast reshaping (Mastopexy) operation. During the consultation, the most suitable type of procedure for the patient, based upon breast size, amount of loose skin, and whether an implant is also used will all be discussed. The scars and final type of shape will vary according to the style of procedure used. However, in simple terms, the nipple is kept attached to the breast but lifted to a new higher and position. Excess skin is removed from the breast and the remaining breast tissue is reshaped. This is all repaired giving an uplifted and firmer breast.

Scars

The scars will depend on the technique used (as above). They tend to be quite red in the first 6 weeks, becoming purple over the next 2-3 months, and then fading to white. Most patients form very good quality scars over time. The length of time will vary in each individual, some patients may take longer or may form raised or stretched scars. The peri-areolar scar can heal very well and is often difficult to see. How other wounds have healed in the past may be an indication.

Smoking

If you are a smoker, try and stop for a minimum of six weeks before and five days after surgery as it can reduce the chances of complications.

Recovering from Breast Lift

Length of surgery

The operation takes 2.0 - 3.5 hours depending on the type of technique used and the size of the breast.

Length Of Stay In Hospital

Usually one night. In selected cases can be proposed a Day Surgery approach.

Dressings

The majority of the stitches are dissolvable and buried. Your wound will be covered in special human super-glue dressings. You may have an elastic dressing on top of this. The dressings will be removed either the following morning or after a few days. You can shower once the dressings are removed. You will be seen by the team after one week to check the wounds.

Drains

It is common to place a small surgical drain into the breast to remove any unwanted blood/fluid for 24-48 hours. A drain is not always required for a simple Mastopexy.

Bras

You should bring a soft (non underwired) sports bra in the planned new cup size into the hospital with you. The bra should feel comfortable, whilst still providing support. You will need to have two bras at home that can be worn on rotation. The chest measurement does not usually change but can reduce by 1-2 inches. You will be able to wear an underwired bra after 8 weeks; this should be properly fitted to your new shape and size.

Time To Exercise

Patients usually feel able to walk a distance at 5-7 days, swim by 10-14 days (if fully healed). Strenuous exercise (aerobics etc) should be avoided for 6 weeks.

Post-Operative Instructions

Day 1-4 You should be taking it very easy! You should not be looking after very young children or doing housework without help.

Day 5-14 You can start doing more activity including walking for longer, shopping, etc. You will have very little pain by the end of this period. If all wounds appear fully healed at day 10 you are unlikely to 'damage' anything by increasing your activity.

Driving

Patients should avoid driving until they are completely free of pain and restriction.

Follow Up

We will check your wound and change the dressing on day 2-3 and again at 7-10 days. You will then have an appointment at 1 month and then 3 months. You will not be charged for any follow-up appointment relating to your surgery.

Periareolar Mastopexy

Circumvertical Mastopexy

Inverted T Mastopexy

BREAST ASYMMETRY

How To Treat Unequal Breast Size?
It is normal for women to have some differences in the size of each breast. However, for some women, the difference is much greater in both size and shape of each breast. We understand this can make a woman feel very self-conscious, as well as cause difficulties with the fitting of bras and clothing.

A lot can be done to improve unequal breast size and shape. Differing approaches are used using a combination of techniques including breast reduction, Mastopexy (breast lift), breast enlargement with implants, fat transfer, and reconstruction with a tissue expander and breast implants.

Types Of Asymmetry

There are three main types of asymmetry:

Developmental Breast Asymmetry

This is the most common type in which both breasts are a normal shape but are simply different sizes. Another common pattern in this group is to have one small conical (pert) breast and a larger breast but with droop.

Tuberous Breast Deformities

This is an abnormal breast shape, most commonly where the breast is very constricted with a very narrow base but a small droopy breast and large nipple.

Polands Syndrome

This occurs when there is an absence of underlying chest muscles and sometimes rib-cage and sternum.

What Can Be Done

This will depend on the size and shape of your breasts, and can be discussed to have one or both treated. If the problem is just a question of size, there are three options:

• The first option is to make the smaller breast larger with an implant (read more about a breast enlargement ) or with fat transfer. This leaves very few scars on the breast. It is important to remember that implants are susceptible to change in shape over the years and may require replacement at some point in life.

• The second choice is to make the larger breast smaller with a breast reduction (read more about a breast reduction ). This will leave scars on the breast but does tend to give a better life long solution in comparison to having breast implants.

• The final choice is to do the same operation both sides (a breast reduction or enlargement) but do a different amount to each side to give symmetry.

BREAST IMPLANT PROBLEMS

Breast Implant Problems And Their Correction

Patients who have breast implants may experience a variety of problems. These can relate to the implant itself (including hardening or capsule formation, rupture, excessive wrinkling, incorrect size) or to a change in the skin overlying the implant (skin or nipple droop, poor quality scars). Sometimes it can be a combination of problems and it is important to have a qualified and experienced surgeon to carry out this challenging procedure.

“Hardening” of Breast Implants (Capsular Contracture)

This occurs when the body forms a layer of scar around the implant that continues to increase. Although not in itself dangerous, it will progress over a period of time. Around 10% of patients form capsules over a 10 year period, and a small number develop them much sooner. Certain types of implants, like the polyurethane-covered ones, may have a lower risk of hardening.

Options for treatment include removing the implant and scar tissue, in some cases to change the implant position and replacing it with a new implant. If a new implant is fitted it will usually need to be slightly larger in size. It is important to note that after removing the implant the final scar can be larger.

Another option is to remove the implant and then reshape the remaining breast using a breast lift (mastopexy). This is an excellent form of treatment if the patient has enough breast tissue to make a reasonable breast shape. If the skin is very lax with hardening then a combination of a new implant and a breast lift can be considered.

Implant Rupture

This understandably causes a lot of concern to patients. It is important to note that even the best quality implants have a small risk of rupture over time. Whilst it can be very alarming, it is usually not an emergency and could be done over a time frame that suits the patient.

Intracapsular Rupture

There is over 40 years of evidence that shows silicone implants, in particular, are very safe. When this type of implant ruptures the silicone can sit within the scar capsule (known as an Intracapsular rupture) without leaking into the breast. In this case, there will be little sign of rupture and is less likely to cause problems in the short term.

Extracapsular Rupture

In more serious cases the rupture can leak into the breast and spread (an Extracapsular rupture). When the latter occurs the implant should always be removed as it can become problematic with the formation of silicone lumps (silicone granuloma), silicone deposits in the lymph glands, and potential deformities of the breast and infections.

Loose Skin, Droop or Poor Quality Scars

Depending upon the scenario the breast can be lifted and the scars re-done. The implants can also be replaced at the same time, but this will depend on their age.

Rippling

This is when the natural folds or buckles of the implant can be seen or felt through the skin. It is more common in patients with thin breast skin or for those that have had implants under the breast and not the muscle.

There are various treatment options including replacing the implant with the last generation of the firmer implant. Transferring the existing implant under the muscle.

Fat Transfer techniques which could make the skin thicker.

Using ADM or Meshes ( special types of material) that is placed on the implant in the affected area that will ‘shield’ the rippling.

FAT TRANSFER

Why the Fat Transfer In The Breast?

Fat injections are used often in conjunction with breast enlargements (augmentation with implants ), Mastopexy, and breast asymmetry procedures.

This procedure improves the shape, fullness, or volume and contouring of the breast by injecting the patient's own fat into the area. This treatment, for both cosmetic and reconstructive purposes, can also be used in the face. Treatment for the breast can be for both breast augmentation and breast asymmetry (differing breast sizes). It is an excellent form of treatment for defects or ‘depressions’ following breast cancer removal.

The results of this treatment are permanent, however, the amount of fat that permanently survives can be unpredictable. Usually, 50% of the injected fat survives and therefore the treatment may require repetition in order to achieve the desired results.

Procedure In Brief

The procedure will be carried as a day-case under local or general anesthesia depending on the size of the area to be treated. The fat is removed usually from the abdomen by Liposuction. After extraction, the fat is specially prepared and re-injected into the breast using small cannulas. There are virtually no scars.

Breast Enlargement (Augmentation) With Fat Injection

The procedure can permanently change the breast size and, is particularly ideal if the patient is already considering investing in having the Liposuction of the thighs or abdomen. The advantage of this treatment as opposed to having breast implants is that the breast will feel very natural. Also, they will not require the repeat operations that implants do when they inevitably need to be changed over time.

It is important to understand that the fat is injected under the skin and breast and not actually into the breast tissue itself. This is to prevent any changes to the appearance of the breast on future scans or X-rays in the future. The scars upon the breast are extremely small and are not noticeable over time. There are small 3-4mm scars for the liposuction on the tummy or thighs.

Large volume changes to the breast are not achievable in one operation. Approximately one bra cup change can be realistically reached in one operation. Repeat surgery is feasible if wanted. As with all fat injections, the survival of the fat in the first few months following the procedure is unpredictable. It varies between 30-80% (average 50%) of the fat injected. The fat that remains after 3-4 months is likely to be permanent.

Smoking

If you are a smoker, try and stop around the time of the procedure as it can reduce the chances of complications.

Length Of Surgery

The procedure will take approximately 30-150 minutes depending upon the technique.

Length of Stay In Hospital

Usually a day case or overnight procedure.

Recovery

The breasts will be swollen and bruised for about 2-3 weeks; the area that has had the Liposuction ( donor areas: thighs or abdomen) will also take the same time to recover.

Bras

Time To Exercise

Patients should avoid strenuous exercise until fully recovered (4-6 weeks).

Driving

Patients should avoid driving until they are completely free of pain and restriction.

Potential Complications With Fat Injections

This is a routine procedure that is a great success for the vast majority of patients. However, as with any procedure, it is very important you understand what can go wrong as well as right. The potential complications are listed below, most of which would only occur if the harvested fat was to be injected into the wrong place.

Lumps and cysts: Some of the injected fat has a small chance of developing into a small lump or cyst. Whilst this is not dangerous, it could potentially appear in a mammogram in future X-rays - and therefore be a cause for concern before being properly identified. However, research evidence does show that any small cysts are usually very identifiable as such.

Breast cancer: There is no evidence to suggest that live fat being injected into the breast causes any cancer changes. Experienced and qualified surgeons inject the fat under the skin and breast and not directly into the glandular tissue further minimizing the risks of any adverse effect.

Bleeding or infection

Loss of volume due to an over resorption of the transferred fat

Altered nipple sensation